Frequently Asked Questions - Autism Mandate

What is the difference between intensive and non-intensive treatment for autism spectrum disorder?

According to the mandate, an individual qualifies for the intensive level treatment if:

the treatment began after 2 years of age and before 9 years of age
minimum treatment hours on average are 20 hours per week or more
the child has a primary diagnosis of an autism spectrum disorder

An individual qualifies for the non-intensive level treatment if:

the minimum treatment hours are less than 20 hours per week on average and
the child has a primary diagnosis of an autism spectrum disorder.

How do I know if the mandate applies to my policy and if so, when does the mandate apply to my policy?

Mandates are required of all fully insured policies (unless otherwise noted above) and therefore, are automatically part of your policy. There is no allowance for “opting out” or turning down the mandate coverage, regardless of whether you or your family will use the benefit.

How do I know whether my child qualifies for this coverage and at what level of treatment?

Once the member has been evaluated by Dean Neuropsychology, you will receive a contact phone number and further instruction. If you have any questions at that point, you may also call the Customer Care Center at (800) 279-1301.

If my child started treatment before the mandate became effective, will you retroactively pay for services that have already begun or for outstanding bills that I have incurred in 2009?

No, the coverage under your insurance plan begins upon the effective/renewal date for your particular plan, and Dean Health Plan will only pay for services received on or after the effective date of the coverage. There will be no retroactive coverage.

Will I be responsible for any costs associated with Autism coverage?

Coverage for Autism Spectrum Disorders may be subject to the same deductibles, coinsurance or copayments that generally apply to other conditions covered under the policy or plan. The coverage may not be subject to any special limitations or exclusions, including limitations on the number of treatment visits.

Please refer to your benefits documents for details on specific coverage which can be found under the Your Benefit Information. If you still have questions, contact our Customer Care Center at (800) 279-1301.

What health care providers can I use if my child needs to get tested for Autism Spectrum Disorder?

If you are enrolled in an HMO plan, Dean Health Plan’s network providers must be used for testing. For Point of Service and PPO plan members, it’s the parents’ choice whether to use an in-network provider.

Note that Point of Service and PPO plan members who choose non-network providers will be responsible for differences in costs associated with seeing non-network providers.

Are the testing and diagnosis covered as part of the mandate?

Testing was covered prior to the mandate and does not count towards the mandated annual maximum benefit for either intensive or non-intensive treatment.

What providers can my child see for treatment? What if we are already seeing a provider that is not in your network?

To obtain an updated list of current providers, please contact the Customer Care Center at (800) 279-1301.

How do you handle Autism Spectrum Disorder patients who are already being covered through the Children’s Waiver Program (Medicaid) or on the waiting list for that program? Is this coverage primary? Does that coverage end?

In these cases, your employer’s plan will be the primary coverage. Your employer plan may require cost sharing, but the Waiver Program may cover these costs. Please consult Medicaid to confirm coverage.

Also, inform your health care providers that your employer plan is primary, so they can coordinate benefits with Medicaid.

Q&A: Autism Mandate